This text was obtained via automated optical character recognition.
It has not been edited and may therefore contain several errors.

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[To be returned to the Circuit Clerk of the County in which the Birth occurs.]
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1. Month, day and year of Birth,. j?. >SVm
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$Color„*.
'Stale if still-born,
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[e?.	I1'iill name, of Father, .	... .^/J
'5. Maine, of Mother previous to m'ai'ridge^.............................................. 
7.	Nativity of Father,........a*£U.......................................................
8.	Nativity of Mother,	.....................
I hereby certify that the above is a true return of the Birth and other facts above recorded.	.	k	::
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Dated at	.........:..
County	....T,Miss , [
this~.t£..tf......day of^Z&£z^..£j£k_______18%t~. J
Residence
*	State whether White, Black, Mulatto, Indian or other Races.	•	1
f Strike out these words if the Return be made by some other person, atid add other explanatory words.
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